Tag Archives: Substance Abuse & Addictions

Substance Abuse & Addictions

A climbable mountain: Quitting smoking and managing mental health

By Bethany Bray August 10, 2020

For people with a preexisting mental health condition, quitting smoking can seem like climbing two mountains at once.

Managing a mental health condition is a daily — sometimes moment-by-moment — challenge, and smoking is often used as a coping mechanism. Understandably, people with mental health conditions who smoke often fear that taking away that source of comfort could send them into a tailspin.

“That was the way I always seemed to manage my stress: Sit down, light a cigarette, and it would make my brain think, ‘It’s going to be OK.’ But in reality, it’s not,” says Rebecca M.* a Florida resident and participant in the Centers for Disease Control and Prevention (CDC)’s Tips from Former Smokers campaign who lives with depression.

Rebecca smoked her last cigarette in 2010. She quit smoking for good — and found balance in her life — with the support of a professional counselor. In hindsight, smoking only made her depression worse, Rebecca acknowledges.

For many people, mental health and smoking go hand-in-hand — you can’t fix one without addressing the other, she asserts.

“Wanting to be healthy, mentally, while smoking is impossible. After I quit, I was able to look at the world with a completely different mindset,” Rebecca says. “Smoking affects every aspect of your life — family relationships, work life, home life. It’s just a cloud. … When I see people who are struggling with mental health [while smoking], I have deep compassion for them. You want so desperately to get better, but with smoking, it’s like taking two steps forward and two steps back.”

In the family

Rebecca says she was “born into a family of smokers.” Growing up, all of her friends and family smoked, so it seemed natural for her to start smoking as a teenager.

She quit smoking for the first time in 2002. However, she started smoking again seven months later as she was going through a divorce and struggling with intense emotions and stress, she recalls.

Throughout this period, she met with several different counselors to help her manage her depression. She had an “aha!” moment in 2009 when her first grandchild was born; she knew then she wanted to quit smoking for good.

“When my oldest grandson was born, it made me stop and think about life in a different perspective. At that time, I reached out to find another counselor, to learn from past mistakes and learn a new way of life,” says Rebecca.

After smoking for more than three decades, she quit fully in 2010, roughly one year after setting the intention, seeking counseling, and going through “some intense self-reflection,” she says. “I was thinking about how I’m a grandmother now, and where do I want to be [in life]? I had a desperate desire to live a healthy lifestyle, and what can I do to get there?”

“Counseling gave me a sounding board, someone I could trust who could give me trusted answers,” Rebecca says.

Since quitting, she says, she has had to examine some friendships with close friends and even family members who continue to smoke. “If they’re not healthy for you, supportive of your healthy lifestyle, it’s important to make those changes as well,” she says. “It was a perspective shift: It’s the difference between being born into a life that you don’t get to choose and choosing the life that you want to live.”

The climb

Professional counselors can help clients meet life’s challenges with an approach based on leveraging the client’s existing strengths. For Rebecca, this included her intention to be a healthy example to her grandson. Practitioners have an arsenal of tools that can help clients make life changes and reach their goals, including smoking cessation.

Rebecca’s counselor helped her establish a self-care routine that includes exercise (she now runs regularly) and meditation. She has come to realize that she needed to exchange one unhealthy behavior, smoking, with a healthy behavior, exercise.

“Nothing will go well unless you take care of yourself first. Counseling taught me how to take care of myself first,” she says.

“[Quitting successfully] is about teaching people about the tools they need. When they are faced with a situation that may make them uncomfortable, or trigger a panic attack or need for a cigarette, they have to have [coping] tools ready and available. For me, it’s been exercise, staying grounded, and focusing on what I can control. I’m [continuing to] educate myself and learn as much as I can so that I can give myself the best self-care I can,” she says.

Most importantly, Rebecca’s counselor helped her accept that her depression, her tobacco dependency, and “all of this was not my fault,” she says.

“I don’t think I could have quit without counseling. I didn’t have the knowledge to do it on my own,” says Rebecca, who turned 63 this summer. “It’s essential to get someone [a mental health professional] who can help you walk this path to healthy living. It’s a path, a journey. It’s one step at a time, one day at a time, sometimes one moment at a time, but it’s empowering. It’s doable, and it feels amazing.”

Rebecca M. has exchanged one unhealthy behavior, smoking, with a healthy behavior, exercise. After smoking for more than three decades, she quit fully in 2010. Photo courtesy of the CDC’s Tips from Former Smokers campaign.

Ten years after quitting smoking, Rebecca’s mental health is good, but she acknowledges that she has to work at it every day. In addition to exercising regularly, she meditates often and tries to approach each day with an attitude of gratefulness, especially for things like a walk on the beach or video chats with her grandsons.

“I’m grateful for every one of those little moments I get,” she says. “It feels wonderful to climb that mountain. … It’s so empowering to be able to overcome tobacco use. There is a lot of life left [after cigarettes], even if you think there’s not.”

Counselors as allies

Professional counselors are particularly suited to help clients quit smoking because the profession has an array of tools focused on behavior modification. Instead of focusing on the health consequences of smoking — as a medical professional might — counselors can instead help clients focus on why they want to quit and how they can leverage their own strength to achieve that goal.

Practitioners also use a holistic perspective to help clients. For example, if a client turns to smoking in social situations because of anxiety, a counselor would help the client address the root cause, finding ways to cope with social anxiety. Similarly, if a client smokes to escape the negative thoughts that can be a constant companion of anxiety, depression, obsessive-compulsive disorder or other mental health conditions, a counselor can equip the individual with techniques to quiet their inner critic.

Read more about the many ways that professional counselor clinicians can support clients on their journeys in the Counseling Today article “What counselors can do to help clients stop smoking.”

In addition to counseling, Rebecca encourages people to use the plethora of tobacco cessation resources offered by the CDC.

“It’s OK to seek help,” she urges. “[Counselors and other professionals] want to see you succeed. You have it in you to succeed. That success is within you; you just have to learn to be kind to yourself and be loving to yourself. That, more than anything, was what I had to learn: to give myself the love that I give others.”

 

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For support to quit smoking, including free coaching, a free quit plan, educational materials and referrals to local resources, call 1-800-QUIT-NOW (1-800-784-8669).

 

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*Rebecca M.’s last name has been omitted for privacy reasons.

 

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Resources

From Counseling Today: “What counselors can do to help clients stop smoking

Find a professional counselor in your local area through the link here: counseling.org/aca-community/learn-about-counseling/what-is-counseling/find-a-counselor

CDC’s Tips from Former Smokers campaign: cdc.gov/ tips

Rebecca M’s page: cdc.gov/tobacco/campaign/tips/stories/rebecca.html

CDC page on quitting smoking: cdc.gov/quit

Additional CDC resources on addressing tobacco use in individuals with behavioral health conditions:

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

School vaping cultures: Acknowledging the impact of COVID-19

By Zachary Short and Nicole Baliszewski June 4, 2020

This past January, global tobacco conglomerate Altria saw a major drop in its stock value on the New York Stock Exchange, depreciating at a value of almost 40% versus its record-breaking highs in 2017. What caused this sudden dip in one of the biggest-rebounding industries of the 21st century? It would be fair to suggest that the COVID-19 pandemic has caused some major complications for both the traditional and electronic cigarette corporations located across the United States.

As a respiratory-based infectious disease, COVID-19 poses an unparalleled threat to the health and safety of individuals across the age spectrum with significant histories of vaping or smoking. In fact, a recent study in the New England Journal of Medicine found that Chinese patients with a history of smoking were twice as likely to suffer from severe infections associated with diseases such as COVID-19 in comparison with those without any smoking history.

Having always opposed the youth vaping/smoking culture, counselors and community advocates across the nation are currently working to answer a significant question: What actions can we be taking to protect our communities from the combined threat of COVID-19 and recent vaping trends?

The truth is, now is the prime time for considering how we can influence our communities to create better post-quarantine schools for our students.

The loss and revitalization of the smoking industry

Only five years ago, health specialists with the Truth Initiative anti-smoking campaign speculated that the tobacco industry and most of the nation’s smoking addictions would expire with the Generation Z demographic. But vaping, the process of inhaling prepackaged aerosols (also known as vapor), has led to the resurgence of nicotine products within school systems.

Through a combination of peer pressure and social media campaigns, students from all backgrounds have found themselves under the influence of Altria’s newest partner, Juul Labs, maker of the Juul electronic cigarette. Largely as the result of the popularization of this flavored electronic smoking device, the number of high school students who use nicotine products has increased from 3.6 million to 5.4 million in the span of only one year, according to the Centers for Disease Control and Prevention (CDC).

How significant it would be to know that schools were free of the harmful aftereffects of adolescent smoking, leaving school counselors and clinicians available to attend to the important mental health developments that are so essential in our school systems right now. Instead, we find ourselves dealing with another truly concerning issue: According to the Truth Initiative, 1 in every 4 high school students now uses e-cigarettes.

These concerning statistics represent a call for preventative action in middle schools across the nation. A number of schools and organizations have taken such counteractions to trends in vaping by launching interventions such as confiscation, disciplinary action, and even educational programming. But the culture of vaping continues to persist as a significant concern for parents and educators.

The most terrifying thing about the Juul product so far is that it appears to come off as being innocuous to many people. Most students and parents recognize it as the small USB-shaped device that produces fruit-flavored smoke. Very few seem to grasp the long-term consequences of vaping habits. That being said, those consequences might already be here.

The individuals at risk

Based on data collected by the CDC in early March, evidence suggests that COVID-19 poses a serious threat to all individuals ages 65 and older. Fortunately for students under the age of 18, the percentage of those infected and harmed has been relatively low by comparison.

While most parents find some comfort in hearing that the student demographic is the least impacted by the pandemic, the statistics can change drastically if students are part of the vaping culture that is rampant among youth. According to data provided by the CDC for China’s mainland population facing COVID-19, individuals with respiratory issues predominantly associated with even a small history of smoking or vaping have a 6.3% case fatality rate, in contrast to 2.3% overall. Recognizing how exposure to vaping increases a person’s health concerns, imagine the increased risks that our students could face should their still-developing physiques come in contact with both nicotine products and a respiratory infection.

“What they say is about 80% of people feel the flu, but they will be OK. Where we are getting into trouble is that it can lead to severe pulmonary distress,” says Anna Song, an associate professor of health psychology and leader of the Health Behaviors Research Lab at the University of California Merced. “Smoking is a risk factor for having this disease progress, be incredibly severe, and lead to mortality.”

As we know, COVID-19 has posed widespread challenges to the health and lifestyles of the global population. Societal and educational norms have begun to deteriorate, and everyday tasks and responsibilities now come with an unprecedented health risk to individuals and their families. Of great concern to us is that the unattended trends and cultures of our school systems could be having a negative impact on our students right now. To allow these trends to persist beyond this pandemic is to continue putting our students at risk unnecessarily.

A unique opportunity for change

What makes now such an ideal time to invest in removing the harmful vape cultures that continue to linger in our school systems? Students are largely being required to undertake remote learning during this time, and that may continue for many students even as a new school year begins. The changes and circumstances that come with students’ remote learning actually promote our greatest opportunity for the development of an anti-smoking culture.

Society is recognizing that our plans, policies and preparation were inadequate to succeed in the face of an unanticipated global pandemic. Thus, things are beginning to change. Legislation is developing to create preventative actions around practices deemed unhealthy by medical specialists, and educational policy is constantly being reformed to reflect the needs and issues present in our impromptu teaching conditions. If there was ever a time to acknowledge the statistics that point to the harm that nicotine products pose to our adolescents and to advocate for the safety of our children, it is now.

Large systemic changes are challenging and often are out of our hands, but educators and parents currently have the opportunity to make a notable difference in students’ environments. During this time of partial quarantine, most families are now all in one location — the home. Our students currently find themselves in a setting where they are under the watchful eyes of their families and where smoking purchases and practices are essentially impossible.

In addition to that, they are also in a potential learning atmosphere. Through the joint efforts of educators and parents, our youth can be exposed to real educational and intimate conversations regarding the dangerous practices of smoking. These conversations can mean the world to students who currently feel that their futures and health might be dictated by vaping culture.

COVID-19 has had a harsh and unpredictable influence on our way of life, but it also presents us with a rare opportunity to support our students through one of the greatest health issues of their generation. So, making use of the present, it is time that we as a supportive community of counselors consider what we should be doing to help facilitate and emphasize this process of growth for students’ mental and physical health.

Our responsibility to intervene

As of early April, individuals within Rowan University’s Department of Psychology have been conducting their own research to confront the vaping culture that remains prevalent during the COVID-19 pandemic. Their research takes an interesting approach to behavioral analysis with younger age groups, including the development of interesting activities such as mobile- and video game-based interventions that promote smoking abstinence.

Fortunately, this is just the tip of the iceberg when it comes to the collective efforts of universities to combat vaping trends in student populations. Even educational institutions outside of higher education are recognizing the statistically supported danger that vaping is putting our students in when facing the current health pandemic. As a community, it is our collaborative responsibility to provide education and to take the necessary precautions to protect our students’ health. We are just beginning to understand the proper steps to take when working from a remote distance.

Educating the community: Providing knowledge of the increased risks and hazards of smoking behaviors is the first step to reducing nicotine consumption within our school systems. Given the myriad resources available on the consequences of vaping from the CDC, the National Institute on Drug Abuse and even university websites such as Johns Hopkins Medicine, it is the obligation of school counselors and other school personnel to appropriately share this information with our local communities. It is important to remember that this information needs to be given not only to the students we support, but also to our educational partners and to the families who are acting as our immediate support systems in homes at this time.

Promoting real conversations: With the knowledge and statistics being supplied to our students’ homes, it is more important now than ever that school systems promote real conversations with students regarding the present vaping cultures. Whether it is school counselor-to-student or parent-to-student conversations, we need to understand what the student perspectives are when they see products such as Juul in the media while also witnessing terrifying statistics regarding the spread of a global virus.

With those who are currently smoking, it is vital that we understand their concerns and interests so that we can provide them the appropriate support they need. These conversations are the optimal opportunity to promote and communicate resiliency, empathy and community support to our students. And with those who have never touched a vaping device, communicating this information and the associated risks is the best possible preventative action at this time.

Advocating for policies: To reiterate, now is a turbulent time when leaders are reflecting on educational preparations and policy and how they might be applied for future incidents. In addition to redesigning our school’s remote learning policies, we need to be working as a professional community to advocate for anti-vaping policies within our schools. It is essential that school counselors reflect on school policies regarding smoking tolerance, as well as preventative actions to take, so that they can create real opportunities to support student health.

Fortunately, states and health institutions are rallying to create a number of anti-vaping models that can be implemented or referenced by school counselors looking to better their schools. One such model is the Make Smoking History campaign, conducted by the Massachusetts Department of Public Health, to reduce the percentage of vaping disciplinary actions taken in middle school settings. This is the time to ask for and support the voices of the education community to find out what should be done for the development of our educational systems — not just on a school-by-school basis, but from a legislative perspective.

Forming support groups: Finally, acknowledging that this is a difficult time for individuals who have a dependency on smoking tools to which they no longer have easy access, we need to prepare and create remote counseling groups to support them through potential issues such as withdrawal or rehabilitation. A number of counselors may struggle with the concept of remote group counseling, but these students still need emotional and mental health support to cope with their new distancing from vaping. Counselors should utilize the medical resources and personnel within their school districts to support students in their transition to healthier living. Ultimately, it is groups such as these that we should be planning to implement more frequently in our later return to school.

The truth is that in the midst of a global health crisis, most individuals view the issue of vaping in school systems as relatively small. But the fact is that vaping is a real health issue for our youth, and in combination with the threat of COVID-19, it puts our newest generation of students at exceptional risk for loss. In a moment in history when many counselors are at home and wondering what they should be doing to support their students, imagine what significant change could occur if we all directed a portion of our efforts to acknowledging and countering the present vaping culture.

 

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Related reading, from the Counseling Today archives: “Pushing through the vape cloud

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Zachary Short is a master’s counseling in educational settings student at Rowan University. He currently works as a clinical research intern in a high school setting, where his research in student behavioral outcomes is being supported through the Mental Health Grant Demonstration Program. Contact him through LinkedIn: linkedin.com/in/shortzachary/.

Nicole Baliszewski is a master’s counseling in educational settings student at Rowan University. She currently works as a clinical intern in a middle school setting, where she seeks to provide trauma and mental health support to the special education student population. Contact her through LinkedIn: linkedin.com/in/nbaliszewski/.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Pushing through the vape cloud

By Lindsey Phillips November 26, 2019

Four years ago, Hannah Rose, a licensed clinical professional counselor in private practice in Baltimore, started vaping as a way to quit traditional cigarettes, but she ultimately found that it was even more difficult to stop vaping. “I was vaping at work, round-the-clock, in between clients,” Rose recalls.

One day after leaving a yoga class, she instantly reached for her vape. In that moment, she felt conflicted because her nicotine addiction did not line up with her values of being mentally and physically healthy. This values conflict made her want to quit, but the thought of doing so gave her anxiety.

Part of Rose’s anxiety stemmed from the fact that nicotine, which is in most vape juices, can be highly addictive. One pod (about 200 puffs) of the electronic-cigarette brand Juul contains 20 cigarettes’ worth of nicotine. Gail Lalk, a licensed professional counselor (LPC) and licensed clinical alcohol and drug counselor in private practice at Young Adult Therapy in Morristown, New Jersey, says she has seen teenagers who have gotten addicted after vaping one or two pods.

E-cigarettes often introduce nicotine to teenagers who were not previously smoking traditional cigarettes. This has been the case for the majority of Lalk’s younger clients. Lalk asserts that she hasn’t had a single client younger than 18 who started vaping because they were trying to quit cigarettes.

Recent statistics confirm the popularity of vaping among teenagers. According to the Food and Drug Administration, from 2017 to 2018, e-cigarette use grew by 78% among high school students (from 11.7% of students to 20.8% of students) and increased 48% among middle school students (from 3.3% to 4.9% of students). In December 2018, Surgeon General Jerome Adams issued an advisory about the dangers of e-cigarette use among teenagers and declared it an epidemic in the United States.

But why have e-cigarettes gained popularity so quickly? The big draw is the flavor, says Rose, who has experience working with clients battling addiction. Traditional cigarettes aren’t known for their good taste. The first time someone smokes a traditional cigarette, they usually start coughing and are left with a tobacco or menthol aftertaste.

Compare that experience with vaping: It doesn’t feel harsh when the user inhales, yet the user still gets a buzz of nicotine. And this experience comes in almost any taste imaginable — mango, mint, apple pie, cake, bourbon, coffee and so on. The options are so plentiful that some online vape shops organize the flavors by categories such as cream and custard, candy, sour and beverage. 

However, after a recent outbreak of lung injuries associated with vaping, e-cigarettes have been coming under increased scrutiny. The Trump administration has proposed a policy to ban flavored vaping liquids, and several states such as Michigan, New York and Massachusetts have already enacted similar bans. In October, Juul announced it was immediately suspending sales of its e-cigarette flavors.

Watch your language

Jennifer See, an LPC and a licensed chemical dependency counselor in private practice in San Antonio, advises counselors to be honest with their clients about the attraction of vaping. “These substances make these kids feel good, even if it’s just temporary. So, saying that they don’t is just not a good approach,” notes See, a member of the American Counseling Association.

Instead, counselors should acknowledge that vaping can be pleasurable and ask clients what they like about it, she says. At the same time, clients can be reassured that they have the ability to quit, even though it will be difficult, and that the counselor will be there with them every step of the way, she adds.

When referring to the issue of vaping during intake or in session, counselors need to be specific about the language they use, See says. Smoking is not “an umbrella [term for vaping] because people don’t really associate [vaping] with tobacco or nicotine,” she explains. “It’s almost its own category.”

On her intake form, See used to ask clients if they were using nonprescribed substances such as alcohol, tobacco or nicotine, or whether they smoked. However, she was finding that clients who vaped often responded no to these questions because they didn’t consider it to be the same as smoking. Now, See clearly asks if clients vape or Juul (the most popular brand of e-cigarettes).

This advice extends to the language counselors use on their websites and in how they advertise their clinical services. Rather than listing only general terms such as substance use or smoking, counselors should specifically list vaping if they are trained and feel comfortable working with the issue, See suggests.

Rose doesn’t believe that vaping should be the focus of counseling sessions, at least not initially. “Vaping is not the problem,” she explains. “It’s just a symptom of the problem. So, counselors [first] need to tap into that core-issue work.”

As Rose points out, even 12-step programs view substances as symptoms of a larger issue. “The 12 steps are not about not drinking [or smoking],” she says. “The only step that even mentions alcohol or nicotine is the first step. The other 11 steps are all about introspective work, practicing integrity, and looking at what patterns of behavior are no longer useful.” The success of this approach lies in looking for the underlying issue, not treating the substance as the problem, she says.

Parents often call See in a panic because they have caught their child vaping and want the child to stop. Parents — typically out of concern and fear — may try to punish or shame their children into quitting. See avoids any hint of shaming her young clients for their choices or even making assumptions about their readiness to quit whatever substances they are using “because I think that is a great way to alienate [the client],” she says.

Rather than launching into a discussion about vaping, See instead starts her sessions by getting to know the client. She will ask about school, home life and friends. She may ask, “What do you do in your free time? What activities are you involved in? Did you recently move? Do you have any pets?”

Often, these conversations reveal the role that vaping plays in clients’ lives, See says. For instance, a client may have started vaping because they just moved and wanted to fit in with a new group of friends, or because they are stressed out about applying to college.

See specializes in substance use and abuse and has expertise working with clients and their family members on issues around vaping. She has found that younger kids want to talk about vaping not only in social settings but also in counseling because they don’t consider it illicit and because they feel it is novel or cool to bring up the latest vape tricks and challenges. One popular challenge is for users to “hit a Juul” as many times as they can for 30 seconds. Another involves the “ghost inhale,” in which users inhale the vapor into their mouths, blow it out in the shape of a ball, and then quickly sip it back into their mouths.

Finding the underlying issue

Using motivational interviewing, See eventually asks clients if they want to quit vaping, if they are worried about their health if they continue vaping, and what their goals are for therapy. Part of the purpose of this questioning is to figure out the underlying reason that clients are vaping in the first place, See says. Is it because they are anxious or depressed? Is it simply because they want to appear cool?

To help clients pinpoint their underlying issue, See asks them to keep a journal to track their thoughts and behaviors connected to vaping. Often, as clients track when and where they vape — for example, when they’re alone in their room, when they’re with friends in their car, or when they’re bored — they also discover the real reasons they do it.

Clients keep track of their vaping habits for a few weeks or in between sessions, and then with See’s help, they look for patterns and clues that point to the underlying reason. This exercise also helps clients gain greater awareness of how much time and energy they devote to vaping, See notes. Often, people spend much more time vaping than they would smoking a cigarette, she adds. “Vaping is almost like chain smoking,” she explains. “That’s just another element that people don’t take into account.” See says some of her clients were vaping for two to three hours per day and didn’t realize it until they started tracking it in their journals.

As Rose notes, “Counseling can be helpful to look under the surface of the behavioral piece and bring a level of mindfulness to what is the thought or feeling that precedes [a client] picking up that vape.” She contends that this is not the time for counselors to use a solution-focused approach to try to quickly get clients to stop vaping.

“Smoking or vaping is a symptom, and the core problem is something internal,” Rose asserts. That’s why she believes counseling has so much to offer to people who want to quit vaping — because counseling goes beyond merely reducing the symptoms and helps to address the underlying issue. “A good competent counselor can really bring a deeper level of awareness to that core issue, [and] if that wound begins to heal, it prevents the problem from continuing,” Rose says.

A few years ago, Lalk, an ACA member who specializes in working with adolescents and young adults, had a teenager come to her because she had attempted suicide, was depressed, had past trauma, and was using lots of substances, including vaping. For the next two and a half years, Lalk worked with the client on her anxiety, depression, and maladaptive behaviors such as lying. After successfully addressing these underlying issues, the client announced on her own that she wanted to quit vaping and be substance free when she started college. In addition to continuing with counseling, the client used a nicotine patch and was able to slowly wean herself off of nicotine. Lalk says this was possible because the client started from a state of good mental health.

A mindfulness ‘patch’

See has had clients who, without thinking, pulled out their vaping devices in session. That showed how much of a habit it had become for them, she says.

Rose admits that she used to be on autopilot with vaping, and the first few days after she quit, she found herself instinctively reaching for her device. Because vaping can help release a person’s anxiety, making them feel better, it can quickly become a habit, Rose says. The challenge is unlearning this habit, which is a deliberate process, she emphasizes.

Similar to See’s tracking activity, Rose has clients journal to help them become more mindful about how and why they vape. She asks clients to write down (or at least notice) what was going on before they vaped, including their thoughts and feelings and their environmental and internal cues. She tells clients not to judge or change the situation. She simply wants them to notice it and make note of it.

“That awareness makes it more difficult to continue engaging in the same self-destructive pattern, and that pain and discomfort lead us to eventually stop the pattern,” Rose says.

Meditation is another effective way for clients to practice nonjudgmental awareness. “Yoga essentially saved me from smoking because it forced me to be still in my own body, and my cravings started to decrease the more I did yoga and the more I got comfortable with myself,” Rose says. “Any kind of mindfulness practice in any capacity can really help calm that craving because it forces you to … pause and be aware instead of act on impulse.”

“When you’re trying to quit vaping, it’s likely to unmask other anxieties,” Lalk says. The trick is to find healthy ways to process this underlying anxiety. Lalk finds patterning techniques helpful for her clients in this regard.

Lalk uses the common technique of deep breathing to illustrate patterning. Counselors often tell clients to breathe in a numerical pattern: Breathe in for four seconds, hold for six seconds, and breathe out for eight seconds, for example. This technique works because of the counting pattern, Lalk says. “Once you start trying to do [this patterning], your brain shifts and it calms you down,” she explains.

Lalk encourages clients to find a patterning technique that works for them. It could be doing beats with their hands, taking deep breathes and counting, writing poetry, or going for a walk and looking for patterns (counting every orange object that they see, for example). The key is to be mindful while doing the activity, Lalk explains. “Running is a beautiful way to pattern because you can count your steps. Just running for the sake of running if you aren’t being mindful about it isn’t nearly as helpful,” she adds.

With the help of a relaxation patterning activity, clients can calm themselves as they discuss their underlying anxiety or other issue with a counselor. Lalk points out that people often hide from whatever makes them anxious. Counselors can work with clients to instead address and acknowledge their anxiety and move toward it, not away from it, she says. Lalk says one of her clients can do four different beats with each of his hands and feet. Once he starts doing his beats, he relaxes and starts talking about his underlying issues.

See also helps clients find mindful replacements for vaping. One of her clients tracked her vaping behavior and discovered that she mostly vaped in her car — a place she spent a significant amount of time driving to school, work and other activities. Together, See and the client reviewed various alternatives that she could engage in while in her car: Would playing music help? Did she need something to do with her hands, such as squeezing a stress ball or play dough or twirling a pen in her fingers? Was her vaping habit the result of an oral fixation?

They finally decided the client would keep a water bottle in her car, and every time she wanted to vape, she would take a sip of water instead. In many cases, it’s about figuring out what clients can do so that vaping is not at the forefront of their minds, See says.

Changing the narrative

Lalk points out that people who vape are not strangers to negative, shame-based and judgmental comments from others. But this sends the wrong message, she says. The person may have tried vaping at a party and, in a short time, become addicted. This doesn’t make them a bad person; it just means they are struggling, she says.

Counseling can help clients manage negative internal and external comments. Rose has her clients practice nonjudgmental awareness. For example, a client might set a goal of not vaping all week, but at the next session, he confesses that he did vape, which in his eyes, makes him a “horrible person.” Rose helps the client separate shame (“I am a bad person because I vaped this week”) from guilt (“I feel bad for relapsing and using nicotine”). Whereas feelings of guilt can be healthy, shame and negative thinking aren’t productive, Rose says. Clients can’t shame themselves into quitting, even though they often try to do just that, she adds.

Rose frequently uses narrative therapy to help clients identify and change these harmful thoughts. She asks clients to write down all of the thoughts they have about themselves at the end of each day. Maybe they vaped that day and feel like a failure, or maybe they went the entire day without vaping and feel good about themselves.

Rose encourages clients to be mindful of the story they are creating with their words and thoughts. She asks clients, “What is the narrative you have created about yourself and your vaping?” Sometimes clients have internalized a narrative of “I’m a smoker,” and the more they say this, the more it becomes true, Rose says. So, if a client states, “I’m a smoker who quit two months ago,” Rose works with the person to change the story to an empowering one, such as, “I don’t vape. I’m not a smoker.”

“Those narratives are going to illuminate some more core issues like self-esteem or a lack of self-worth,” she adds.

Focus on the wins

See suggests that counselors can also help clients focus on their small victories. “Every time you don’t [vape] is a win,” See says. “And if a day didn’t go as great as you wanted it to, then just press that reset button and start over. You can start over at any point in the day. You don’t have to wait until tomorrow.”

See collaborates with clients to identify rewards and motivations that would work best for them. That could be buying new shoes with the money saved from not vaping that week or not allowing themselves to watch a Netflix show until they make it one day without vaping. The goal is to have clients build up their toolboxes, so she has them come up with a list of about 25 things that aren’t substances that make them feel good, such as running or going out to eat at a favorite restaurant.

Having a sufficient stockpile of motivators in their toolboxes ensures that clients will have an alternative to turn to when the craving to vape hits, See notes. Having only a few options — even if they are strong motivators — can backfire because not every tool will work in every situation. For instance, if a client is stuck in class and can’t go running when the urge to vape arises, he or she will need another tool to use in that moment. Clients should also make their goal visible to help motivate them, See adds. For example, they can put the goal on their mirror so that they see it every day.

Rose recommends the app Smoke Free because it focuses on positive reinforcement, not consequences. “It’s very strength based,” she notes. The app doesn’t show a picture of an unhealthy lung or treat the user as naive. Instead, it focuses on the benefits of not smoking and the progress people are making toward their goals.

Upon opening the Smoke Free app, users see a dashboard displaying how long (down to the hour) they have been smoke free. It calculates the degree to which the person’s health is being restored with icons that display improvements (by percentage) for pulse rate, oxygen levels, and risk of heart attack and lung cancer. It also shows users how much money they have saved by not vaping. The app includes a journal component where users can note their cravings and identify their triggers. To further encourage users, it includes progress made such as life regained in days and time not spent smoking.

“A knowledge of consequences does not dissipate the problem,” Rose says. “We absolutely know that smoking is highly correlated with lung cancer, and yet millions of people still smoke.” Younger generations often feel invincible, so focusing only on the consequences of vaping isn’t a sufficient motivator, she adds.

Forming alliances

Counselors must take steps to reach children and parents even earlier because vaping is increasingly making its way into elementary and middle schools, says See, who wrote the article “The dangers of vaping” for the website CollegiateParent. With parents, it is also helpful to educate them on what to look for because vaping devices, which can resemble a flash drive or pen, are often hidden in plain sight and are easily overlooked, See adds. 

Lalk recommends that counselors also take the time to learn from their clients. Through her alliance with some of her seventh- and eighth-grade clients, she found out which local stores were selling e-cigarettes to underage patrons. These clients also confided that one store owner said he knew the kids were underage but that the possibility of getting caught and having to pay a $250 fine was worth it because each vape sold for $60.

This knowledge helped Lalk take action in her community, including writing an article on how the shops, rather than the children, should be prosecuted, and participating in a movement to create ordinances setting new rules for establishments that sell vapes to minors. The businesses in her town now have to secure permits to sell vaping products, part of which requires acknowledging that they will not sell to minors. If store owners are found in violation of their permits, they risk losing their businesses. 

Rose used to facilitate two hours of group counseling at a rehabilitation center five days a week, and she regularly witnessed the shame reduction and healing that can happen in groups. “I believe the opposite of addiction is not just abstinence,” she says. “The opposite of addiction is connection.”

Accountability is another big piece in quitting, Rose says. She often tells clients who are struggling to call a friend with whom they can be honest or to find another way to keep themselves accountable to their goal of quitting or reducing the amount of time they vape.

Rose personally found that documenting her journey of quitting in a blog post kept her accountable. Others reached out and told her that her post made them feel less alone and motivated them to quit too. In turn, she thought twice before using her vape again because she wanted to respond to incoming emails by confirming that she was still vape free.   

See agrees that accountability and healthy rewards are smart strategies for helping clients who want to quit vaping. Peer pressure can become a big issue, especially for teenagers who don’t want to feel like the odd person out when seemingly everyone else in their crowd is vaping, she says. She advises clients to let people know they are quitting and to surround themselves with people who will empower and support them in their decision.

Accountability becomes even more important with adults, See points out, because they have more freedom and don’t automatically have someone watching over or checking in with them. That’s why having a support system is so important, she says. When clients feel like vaping, they can reach out to someone they trust and ask them for five reasons not to, See says.

See says clients might also consider posting on social media that they are quitting and openly ask for support, or they could participate in a 30-day challenge. One of Lalk’s clients participated in a challenge the person referred to as “No-Nic November.” These positive challenges can provide a good counterbalance to the vaping challenges that are so popular on social media currently.

When See dropped one of her children off at college, she noticed the dorm had placed a whiteboard with the words “Healthy Ways to Deal With Stress” written at the top. The students were adding their own suggestions, such as going to a pet store and petting a cat or going for a run. See loved this self-empowering technique and plans to incorporate it into her own practice by adding a Post-it wall where clients can add their own healthy ways of coping or their own words of encouragement.

Taking the first step

Quitting can be overwhelming, and sometimes clients don’t know where to start. See advises these clients to begin by taking small steps. Harm reduction can be a particularly effective early strategy because it empowers clients, See says. “Once they see they can harm reduce, then maybe [they] can harm reduce all the way to zero use,” she explains. “But putting them at the bottom of Mount Kilimanjaro and saying ‘get up to the top right now’ is daunting.” Instead, she asks clients what their “climb” to being vape free looks like for them. Do they want to climb fast, or do they want to climb slow?

Recently, See worked with a teenager who had been vaping for three years. She had been scared by the recent health reports related to vaping and wanted to quit. See asked this client about her motivators, and the client said she wanted to quit to protect her health, for her parents who were pressuring her to quit, and because of the monetary costs associated with vaping.

See asked the client, “What does 30 days without vaping look like?” The client’s eyes bulged. The thought of it was too much for her. So, instead, See and the teen client talked and decided she would remove e-cigarettes from just one place in her life.

By tracking her habits, the client learned she vaped mostly in her car. So, See suggested she remove the vape only from her car and also not allow her friends to vape there. See also instructed the client to notice and write down how it felt not having the vape in her car. Did she miss it? Did she reach for it without thinking? Together, they also made a list of possible replacements she could keep in her car, including a pen, candy flavored like her favorite vape juice, and a stress ball.

“That was one part of the mountain that she could climb,” See says. Feeling empowered by her success, the teenager eventually decided that she was ready to tackle the prospect of no longer vaping in her room at home.

Others, such as Rose, decide to take a faster approach and quit cold turkey. She notes that counseling can bring a level of mindful awareness to quitting and help clients figure out the underlying reasons they turn to vaping to fill an internal void. “The nicotine [and] physical addiction is a part of it, but that’s not the core issue,” she asserts.

Since she stopped vaping, Rose’s mindfulness practice has increased. She has trained herself to pause before acting on impulse. “The mental aspect is infinitely more difficult to unlearn than the physical addiction — ‘I’m sad, I’m going to vape. I’m happy, I’m going to vape. I’m bored’ — that’s the most common — ‘I’m going to vape.’ It’s something to do, something to reach for, essentially something to [help] avoid just sitting with [one’s] self in one’s own skin,” she says.

As Rose opens her Smoke Free app, her dashboard proudly displays that she hasn’t vaped for six months, 16 days and 13 hours.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Healing the healers: Counselors recovering from familial addiction

By Suzanne A. Whitehead October 8, 2019

It has been roughly 17 months since I wrote a piece for CT Online about my son’s struggle with addiction, and it is amazing how far he and our family have come since then. I felt compelled to write a follow-up, not just because he is my son, but also because in the past year, I have discovered that so many professional counselors’ and counselor educators’ family members suffer in silence.

Last year, I used an author pseudonym in my article. I did this for two reasons. First, out of respect for our son because he was still in residential treatment and I couldn’t ask him for permission at that time. Second, I wanted to preserve anonymity for both of us, afraid of the effects that discussing our story and revealing our identities might have. A lot has changed over the past year, however, and today, both my son and I are so much stronger for having the courage to speak out. We no longer hide behind the effects of this horrible disease. I have learned that by speaking up, the addiction no longer holds any power over our family. I hope in this article to offer some solace, support, understanding and love to those who are suffering in silence. We healers deserve to heal too, and my heart goes out to you all.

On Feb. 16, 2018, the police called us at 2:30 a.m. from the other side of the country — 2,600 miles away — to tell us that our beautiful, precious son had been found on the side of the road, passed out. We later learned that the heroin in my son’s possession had been laced with fentanyl–he had no idea. Heroin users never have any idea what they are truly getting. They assume it is the same product that they are used to, draw up the same “dosage,” and a few seconds after injection, it’s all over.  The police  told us  that they had found our son just in time. He was in the cab of his truck, his foot still balanced on the brakes, the heroin and needle next to his side, the tourniquet still strapped to his arm and accompanied by his faithful dog, who barked like crazy as the police pounded on the door. It is a miracle our son is still with us. It is even more miraculous that he now has over 14 months in recovery and in order to pursue what he calls his life’s work, is studying to become a substance abuse counselor.

I wish I could share with you the “miracle formula,”– a path that if everyone could just follow, they would be “OK.” If only … But, this disease of addiction doesn’t work that way. It has a mind of its own, and its victims must find the recovery that best works for them.

I attended the American Counseling Association Conference & Expo in New Orleans this past March and went to a session proctored by Geri Miller (author of Learning the Language of Addiction Counseling). She, along with two other presenters, Jennifer Kline and Ben Asma, tried to describe the nature of addiction to the audience: how tolerance builds up, how the brain becomes “hijacked” by the opioids, and the realities of withdrawal. They did an outstanding job  relaying what actually happens to a human being, and came as close as I’ve ever heard to describing the abject horror a person suffering from addiction must endure.

For those of us who have never experienced or witnessed a person in withdrawal (I am not a person in recovery, but am a licensed addiction counselor and professor who teaches addiction and counselor education), it is hard for people to truly understand its hell. My son had to go through it on the floor of a jail cell, writhing in agony. An addict no longer uses to get high – that ship has sailed a long, long time ago. They use only to avoid withdrawal.

When withdrawal starts, you begin to feel like you are becoming quite physically ill. Soon, you begin to sweat all over, then have uncontrollable bouts of freezing. Your skin begins to crawl; you start seeing double. Your gut aches as it never has. And then you begin to wretch violently.

Simultaneously, you lose control of your bowels, and getting to the toilet is no longer an option. The pain continues to grow as you lose the ability to stand up. Your stomach contorts and your head is in agony. You want to rip out your hair, your eyeballs, anything to make the wretched pain stop. You continue vomiting and soiling yourself, every few moments. There is no reprieve, no solace,  no hope. You are so “dope sick” now that you think you may die and loathe yourself so much that you no longer believe you are even worth saving. You know the one and only thing that will make this sheer hell on earth stop is if you can get some drugs in your system. You swear by all you have left within you that you will “quit tomorrow.” You must tell yourself this lie, because to realize that you can never quit on your own is too unbearable to fathom.

After several hours, or even a day or two of the above, you will do anything (just about) to get more drugs. You despise your very being, your reflection in any mirror, and the lies you constantly tell to the ones you love the most. Your shame and guilt seem insurmountable. Your spirituality is gone – it was one of the first things the drugs took away from you. There is no longer any hope, just the temporary relief of the heroin (or worse) coursing through your veins.

Each day, or several times per day, this hell is reenacted. Depending on tolerance, what you took, how often, withdrawals can start again in a matter of hours. When a person must detox without the benefit of using buprenorphine or a combination of buprenorphine and naloxone to slowly, medically and safely wean them off the substances, the hell can last for days or a week or more. Withdrawal from heroin use is rarely fatal; however, there are many serious side effects and people can die from dehydration. If they are not safely detoxed, their pulse often becomes thready, their PO2 oxygen levels drop, their blood pressure plummets and they may even slip into unconsciousness or start seizing. This is what happened to my son. The guards had to rush him back to the hospital after 36 hours to give him IV fluids. He was so gravely ill that he barely remembers this part. The hospital personnel patched him up and within a few hours, he went back to his jail cell. How we treat people who have unwittingly taken too much OxyContin and become victims of the pharmaceutical trade is unconscionable. It is now known that a person can become addicted to OxyContin within five days. And we treat these people, human beings, worse than wild animals.

To know my son survived this horror, alone, with nothing but Tylenol and something mild for nausea (which is vomited immediately), tears at the very fabric of my soul and violates all I hold sacred in this world. How he was treated was vile, but not uncommon. Many others who suffer from addiction and end up in jail receive the same treatment. They will face the legal system, as my son did, and pay for their crimes. But the horrendous lack of treatment, access to care or compassion, combined with the sheer inhumaneness they face, brings me to my knees. If people only knew…

There is no question that many people do horrid things when they become victims of addiction; the realities are painfully obvious. A cornerstone of recovery is the process of paying for  mistakes and learning how to make amends. Forgiveness from loved ones can come at a very heavy price, and forgiving oneself can ultimately become the hardest fought battle of all. Addiction is such a cruel, insidious disease, particularly because so many have such a difficult time in separating the behavior from the person. Understanding the horrible acts that some people commit, while also trying to see them as a person in severe emotional, physical and spiritual pain, is a significant and sometimes difficult juxtaposition. For those living with addiction, free will has been overtaken by the demands of withdrawal, and the self-deprecation that follows each usage is beyond daunting.

My intention in writing this piece is to help convey the utter destruction of opioid addiction and the ugly and purulent aspects of withdrawal. Once we truly understand this part of the disease, our entire paradigms change. It would be unconscionable to treat someone with cancer, heart disease, diabetes or emphysema this way. Yet we allow this to go on day after day after day. We lose over 116 dear souls to opioid overdoses in this country every day now, and the numbers continue to rise. We all share this plight because addiction can, and does, happen to anyone. Once we understand this, we can stop the blame and shame that has for centuries accompanied this disease and begin to proactively act.

Our son is still fighting this disease; he will for the rest of his life. So far, he is winning, but elements that test his recovery are always there. We continue to celebrate his victiories. The entire family went to his open Narcotics Anonymous meeting to watch him get his one-year keychain and cheered like crazy fools. The look of pride in his eyes said it all: it’s as if his life is now just beginning. He’s been volunteering 30 hours per week at a county outpatient and residential treatment center since September 2018 as he works on attaining his certification to treat those with substance use disorders. His compassion for those fallen is unparalleled; he “gets this.” His family couldn’t be prouder. What an incredible difference he is making in the lives of others every day. He is my hero, and I stand in awe of his contributions and bravery.

Narcotics Anonymous keytag (via newyorkna.org)

My other goal in writing this is to discuss the stigma that helping professionals face when our own loved ones confront addition. That reality persists, and when I feel brave enough to reach out, I have overwhelmingly found that so many others also suffer in silence. Because we are counselors, therapists, professors and educators, we—and others—believe that not only do we help heal others, we must somehow have all the answers and will always know and have the ability to intervene in cases of addiction — especially with our loved ones. The assumption (I surmise) goes that there is something gravely wrong with us when a loved one succumbs to addiction. Why didn’t we intervene and stop them? Unfortunately, it’s not a matter of becoming aware and then simply “stepping in.” Addiction is a bio-psycho-social-emotional disease, insidious in its approach, and deadly in its tracks. It is not exclusive and honors no perceived barriers — not religion, socio-economic class, ethnicity or any other categories or factors. Because secrecy, lying, excuses, stories, deception, and falsehoods are all part and parcel with this disease, even the most astute of us do not always recognize the signs of impending addiction. Before long, victims are well into their disease and, by necessity, the level of deception grows with each passing day. It’s called survival.

To blame the person who is addicted for using their survival instincts is antithetical to any help we can give them. So too is to blame the family members and loved ones, no matter their profession. The isolation I felt this past year was heart-wrenching, lonely, judgmental, sad, destructive, and purposeless. I have also found that this sense of isolation is shared by many of my comrades. I am mentally exhausted from hiding in the shadows, fearing recriminations and judgments from those who refuse to listen or understand.

As I test the waters and disclose our story, I am buoyed by the knowledge that there are so many of us who need a voice. We need to raise awareness that this disease knows no bounds and its victims are all of us. It’s time to stop letting addiction win. It’s time to stop being its unwitting counterparts. It’s time to treat the addicted person, the family, and the loved ones with humanity and compassion —- the same way we treat others with any type of potentially deadly disease. I’m determined to not let my professional colleagues suffer in silence. I feel your pain; I understand. Now, let’s get the word out.

 

 

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Suzanne Whitehead is coordinator of the counselor education program at California State University, Stanislaus. Her main research interests include promoting increased access and humane treatment for those afflicted with substance use disorders; crisis and disaster counseling; and equity for DACA recipients, immigrants and refugees. Contact her at swhitehead1@csustan.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Suicide, substance abuse and medical trauma

By Bethany Bray September 3, 2019

Gunshot wounds, injuries from automobile accidents, a fall from a ladder, cooking burns or other incidents, either self-inflicted or unintentional: These are a few examples of the medical trauma that brings patients to the Wake Forest Baptist Health (WFBH) Medical Center in Winston-Salem, North Carolina.

Elizabeth Hodges Shilling and Olivia Smith are part of a team of counselors who talk with trauma patients at WFBH and assess them for suicidality and alcohol or substance use. The counselors have a laundry list of questions to ask patients as part of the assessment, but patients are often reeling from the traumatic incident that brought them to the hospital. At the same time, the counselors have a limited amount of time to work with each patient because patients are usually under their care for only 24 to 48 hours.

The solution? Shilling and Smith say they use a lot of “tell me” or “tell me more” questions and prompts. It’s a gentle way of getting the information they need and connecting the patient to additional resources.

For instance, instead of directly asking patients whether they drink or use drugs, Smith might say, “Tell me about when you’ve used alcohol or drugs to help you calm down or when hanging out with friends.” These types of inquiries make patients more likely to respond and open up, according to Smith, a coordinator and counselor on the adult and pediatric trauma screening and brief intervention team at WFBH.

This can be especially true with teenagers and young adults, who can be quick to put defenses up. “Sometimes we preface our questions with, ‘I’m not here to try and stop you. I just want to understand and try and support you,’” Smith notes.

Shilling and Smith are both licensed professional counselors and licensed clinical addictions specialists. They say that framing their assessments as “conversations” can help to form a connection with patients who might be overwhelmed by all the questions they’ve been getting from doctors and other medical personnel.

“Tell me about” questions are a gentle way of building rapport and opening the door to get more information from patients, says Shilling, an assistant professor in the department of surgery at Wake Forest School of Medicine. It also lets patients know that the issues with which they might be struggling aren’t unusual; other individuals are struggling with them as well.

The counselors may use prompts such as, “Tell me about the last time you thought about hurting yourself” or “Tell me about the times you’ve tried to cut down on your drinking,” says Shilling, a member of the American Counseling Association.

“Just throwing it into the conversation and bringing it out in the open gets them thinking about it,” Smith says. “[Also,] it eases up on the stigma about these thoughts and normalizes that it happens. We often hear embarrassment, and [patients who say,] ‘I’m having these thoughts, and I don’t know what to do with them.’”

Roughly 50% of the trauma patients they see at WFBH are admitted because of an accident or incident related to alcohol, Shilling says. This includes suicide attempts while under the influence of alcohol, intoxicated driving or being a passenger in a car with an intoxicated driver, or a variety of injuries that occur after a person has been drinking. Hospitalwide, one-third of patients are admitted for a medical condition related to substance use, she says. This includes conditions exacerbated by long-term alcohol use, such as pancreatitis.

“We often see people who have never thought about making a change, or others who have been injured several times and it’s a wake-up call and they want to change. Alcohol use can be a big part of their situation but also a small thing, as they’re dealing with so many things at once,” Smith says. “Being in the hospital posttrauma really facilitates the opportunity to think about making changes in your life. … It’s a teachable moment and opportune time to reassess [your choices].”

 

Alcohol and suicide

Smith and Shilling urge mental health practitioners to include questions about alcohol and substance use when screening clients for suicidality. This is a vitally important area of risk that often gets overlooked in suicide assessment, Shilling says.

Substance use problems are one of many suicide risk factors included on a list on the American Foundation for Suicide Prevention website, afsp.org.

Substance use can increase a person’s impulsivity, and it numbs the parts of the brain that trigger thoughts and behaviors that keep a person safe, Shilling says. “We see patients who, when sober, say they would not have taken those pills or used their gun, etc. But when they drink, that rational piece [of brain function] gets overridden. Using substances puts you at particular risk.”

Additionally, substance use can have negative effects on the overall mental health and wellness of patients, even if they do not exhibit signs of a substance use disorder. Asking questions about substance use can help patients understand how their drinking or substance use affects the whole picture, including mental health and mood, Shilling says.

“Substances impact their mental health in a lot of ways. They may be using substances in a way that’s not risky per se, but it may be affecting their mental health,” she adds.

Shilling urges practitioners who want to learn more about substance abuse — especially those who work with vulnerable populations such as teens — to seek continuing education or even additional licensure (such as becoming an addictions specialist).

 

Asking the right questions

Smith and Shilling’s cohort at WFBH uses several screening tools to assess for substance use in the patients in the hospital’s trauma, burn and medicine units.

The first is the Alcohol Use Disorders Identification Test (USAUDIT) developed by the U.S. Substance Abuse and Mental Health Services Administration. Available to the public at ct.gov/dmhas/lib/dmhas/publications/USAUDIT-2017.pdf, the assessment places users into one of six categories, ranging from “low-risk alcohol use” (no more than 14 drinks per week for men and seven per week for women) to “alcohol dependence” (which includes a cluster of symptoms indicating dependence on alcohol).

The Wake Forest team also uses the CAGE Substance Abuse Screening Tool developed by the Johns Hopkins School of Medicine. Smith says this mnemonic screening tool helps prompt patients with open-ended questions:

Cut down: Have you ever felt you should cut down on your drinking?

Annoyed: Have people annoyed you by criticizing your drinking?

Guilty: Have you ever felt bad or guilty about your drinking?

Eye-opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

Read more about the CAGE screening tool at hopkinsmedicine.org/johns_hopkins_healthcare/downloads/all_plans/CAGE%20Substance%20Screening%20Tool.pdf

 

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Call for help

The National Suicide Prevention Lifeline offers free and confidential support around the clock, seven days a week, at 800-273-8255 or via chat at suicidepreventionlifeline.org.

 

Read more about addressing the topic of suicide with clients in Counseling Today‘s September cover story, “Making it safe to talk about suicidal ideation.”

 

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Contact the counselors interviewed for this article:

 

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Bethany Bray is a senior writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.